Commercial Licensee Notice of Loss/Theft Form

Commercial Licensee Notice of Loss/Theft Form

Greetings,

**Submission of the required information within 24 hours after discovery of the event**

442:10-5-13. Loss and theft

If a commercial licensee has reason to believe that an actual loss, theft, or diversion of medical marijuana has occurred, the commercial licensee shall notify immediately the Department and law enforcement. The commercial licensee shall provide the notice by attaching and submitting electronically a signed statement that details the estimated time, location, and circumstances of the event, including an accurate inventory of the quantity and type of medical marijuana unaccounted for due to diversion or theft. The notice shall be provided no later than twenty-four hours after discovery of the event. Please provide the following information.

OMMA License Number:*

XXXX-XXXX-XXXX

Business Name*

(Legal & trade name, if appliable):

Physical address of the licensed premises where the event occurred

(to include city, state, and zip code):

Date of loss/theft*

(if the actual date is not known, please estimate):

Estimated Time

(HH:MM):

Please give a detailed and accurate inventory of the quantity and type of medical marijuana unaccounted for due to this theft, loss, or diversion

(if you need additional space, please provide a separate sheet with this form and upload it.). Please note that completion of this form does not substitute the licensees responsibility to accurately report a licensee inventory of medical marijuana in the State inventory tracking system.

I certify that all the information provided on this form is true and accurate to my knowledge.*

Printed Name

Date:*

Job Title*

Please upload the following:

Commercial Licensee Notice of Theft/Loss Form

Police Report and any pertinent information.

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